Assessing the impact of SMS-based interventions in promoting family planning uptake and modern contraceptive utilization in sub-Saharan Africa: a systematic review and meta-analysis

Abstract

Background

Modern contraceptive use in Sub-Saharan Africa remains low. Limited access to accurate and culturally-appropriate reproductive health information continues to hinder family planning uptake, affecting reproductive health outcomes. With a large percentage of the region’s population owning a mobile phone, Short Messaging Service (SMS) interventions are a promising solution to improve outcomes. This review assessed the impact of SMS-based interventions on enhancing modern contraceptive uptake in the region and identified key barriers and facilitators.

Methods

Following the PRISMA guidelines, we searched PubMed, Cochrane Library, and Google Scholar for relevant peer-reviewed studies. Eligible studies were peer-reviewed interventional studies published between January 2010 and December 2024. Data extraction was conducted by independent reviewers, and pooled odds ratios were calculated using the random-effects model in R 4.4.3. Study quality was assessed using Cochrane Risk of Bias tools and Joanna Briggs Institute checklists. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Thematic synthesis was used for qualitative data.

Results

Sixteen studies (n = 16,849) across seven countries were included, including 10 randomized controlled trials, four quasi-experimental studies, and two pilot studies. SMS content included clinic reminders, educational content, and service accessibility information. From the meta-analysis, SMS interventions significantly improved contraceptive uptake (OR: 1.41, 95% CI: 1.26–1.57). Greater effectiveness was observed for longer durations (OR: 1.91 vs. 1.37; p < 0.0001), two-way messaging (OR: 1.76 vs. 1.39; p = 0.04), and personalized content (OR: 1.78 vs. 1.38; p = 0.03). No significant variation was found across sub-regions or population groups. There was no improvement in modern contraceptive knowledge. Key facilitators included confidentiality, simple language, and postpartum care integration, while barriers included spousal resistance, phone access limitations, literacy challenges, and fears of side effects.

Conclusion

SMS-based interventions are promising at improving modern contraceptive uptake, and should be scaled further to maximize impact. Future interventions should address key barriers while leveraging facilitators to maximize success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-27869-1.

Background

Globally, 1.1 billion of the 1.9 billion women between the ages of 15 and 49 require family planning. According to the United Nations, over 164 million people have unmet needs for family planning [1]. The proportion of women globally whose family planning needs are covered by modern means peaked at almost 77% between 2015 and 2022 [2]. Sub-Saharan Africa, however, had minor growth throughout the same period, rising from 52% to 58%, and this data point is crucial to achieving Sustainable Development Goal (SDG) 3.7.1 which focuses on ensuring universal access to sexual and reproductive health care services [2, 3].

In 2024, 49% of people worldwide used contraceptives, with sub-Saharan Africa coming in last at 29% [4]. In sub-Saharan Africa, the prevalence of contraception is low and the unmet need for contraception is high; therefore, access to and use of family planning services continue to be significant public health concerns [4]. Misconceptions, rumours, myths, or misperceptions regarding modern contraceptive methods and use, gender and stigma towards young people, unmarried people seeking contraception, male-dominated decision-making in reproductive health, and restricted access to proper information are some of the obstacles [4–7]. Mobile phone features like privacy, portability, and ubiquity may help get past some of these obstacles; therefore, using them to spread family planning information has potential [5].

Capitalising on the rapid expansion of mobile phone usage in sub-Saharan Africa, mobile health (mHealth) interventions, particularly those delivered via Short Message Service (SMS), are being used more frequently to encourage reproductive health behaviours. SMS interventions are attractive for reaching young people and rural populations because they permit confidential contact, act as reminders, and offer personalised health education to men and women of reproductive age across the full spectrum of modern contraceptive methods [5, 8]. The effectiveness of SMS interventions in enhancing modern contraceptive knowledge and uptake is supported by a growing body of evidence. For example, Rokicki et al. found that both unidirectional and bidirectional SMS messages significantly improved contraceptive knowledge at three months, with gains persisting at fifteen months, and that bidirectional communication outperformed unidirectional messaging in improving reproductive health awareness [9–11]. McConnell et al. similarly reported increased postpartum contraceptive use among new mothers in Kenya following SMS appointment reminders. Compared to mass media campaigns of comparable reach, SMS interventions offer a more targeted and adaptable approach to improving family planning knowledge at considerably lower cost [10].

The results from several studies differ. Unger et al. [11] noted that the extent to which SMS communication content influences behaviour change is unclear. Certain observational and pilot studies indicate limited or context-specific impact, with effectiveness varying by gender, age group, and the type of message content [11–13], despite the fact that numerous randomized controlled trials have demonstrated positive outcomes [14, 15]. Furthermore, Laidlaw [16] points out that cultural beliefs and degrees of digital literacy could affect the results of interventions, highlighting the necessity of user engagement tactics and locally relevant information. However, there are scarce evidence syntheses describing SMS therapies’ efficacy throughout Sub-Saharan Africa, despite growing interest in and use of them. Thus, the purpose of this systematic review and meta-analysis is to evaluate how SMS-based interventions affect the region’s use of family planning and contraception.

Methods

Study design

This was a systematic review and meta-analysis on the impact of Short Messaging Service interventions in promoting family planning and modern contraceptive uptake in Sub-Saharan Africa. The review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria [17]. The PRISMA checklist for this study is provided in the supplementary material (Additional file 1). We registered the protocol for this study with the International Prospective Register for Systematic Reviews (PROSPERO), CRD420251045053. No significant deviations from the registered protocol occurred during the conduct of this review.

Inclusion criteria

To find and select the right studies, the PICO (Population, Intervention, Comparison, and Outcomes) framework was used. We included studies that met the following criteria:

Population

This review included studies conducted in all populations of Sub-Saharan Africa, including key populations such as pregnant women, adolescent girls and young women, men, female sex workers, LGBTQIA+, and youths. Population categories were retained as reported in the original studies. For the purposes of this review, studies were categorized as involving the “general population” when participants were recruited from the broader community of men and women of reproductive age without restriction to a specific demographic or key population subgroup. Studies had to be published between January 2010 and December 2024. This timeframe was selected because it aligns with the period during which the use of mobile phones began to expand in African settings, and including studies up to 2024 ensured the review incorporated the most recent evidence on SMS interventions for family planning and contraceptive utilization.

Intervention

Studies that assessed the impact of short messaging service interventions on family planning and modern contraceptive uptake were included.

Comparator

Studies with any type of control group, or without control groups, were included.

Outcomes

The review included studies that address the following outcomes.

Primary outcome

The primary outcome was the effect of SMS interventions on modern contraceptive utilization in Sub-Saharan Africa. In the context of this review, family planning uptake encompasses engagement with any family planning service or method (including contraceptive adoption, attendance at family planning counselling sessions, and adherence to prescribed contraceptive regimens) following exposure to an SMS-based intervention. Modern contraceptive utilization is defined as the current and sustained use of any clinically recognized modern contraceptive method by women or couples of reproductive age (15–49 years). Such methods include devices, medications, procedures, and behaviours that prevent pregnancy, such as oral contraceptive pills, injectables, intrauterine devices (IUDs), implants, male and female condoms, and permanent sterilization.

Secondary outcomes

These included the barriers and facilitators affecting the effectiveness of these SMS interventions. We also assessed the impact of interventions on modern contraceptive knowledge.

Design of eligible studies

Eligible studies were primary studies evaluating the effectiveness of SMS interventions targeting family planning or modern contraceptive use in Sub-Saharan Africa. These consisted of randomized and non-randomized controlled trials, comparative pre-and-post studies, and quasi-experimental studies reporting outcomes from interventions. Only studies written in English were included in this systematic review.

Exclusion criteria

We excluded studies that had inaccessible full-texts or studies with interventions conducted outside of Sub-Saharan Africa. We excluded observational studies that reported no interventions. We excluded conference abstracts, commentaries, editorials, reviews, and study protocols.

Search strategy

A comprehensive search of PubMed, the Cochrane Library, and Google Scholar was conducted using keywords such as ‘SMS,’ ‘short messaging service,’ ‘family planning,’ ‘contraceptives,’ and ‘Sub-Saharan Africa.’ Keywords were combined using Boolean operators, field tags, and MeSH terms. We also hand-searched the reference lists of included studies and relevant reviews to identify additional eligible articles. The systematic search was limited to these electronic databases and reference-list screening. A separate comprehensive search of grey literature sources (e.g., institutional repositories, policy databases, conference proceedings, organizational websites) was not undertaken. However, grey literature records such as theses or dissertations that were incidentally identified through database searches or reference lists were assessed for eligibility and included where they met the predefined inclusion criteria. The detailed search strategy is available in the supplementary file (Additional file 2).

Study screening and selection

After the databases were searched, all entries were imported into Rayyan for deduplication and screening. After the databases were searched, all entries were imported into Rayyan, a web-based systematic review management platform, for deduplication and screening [18]. In this review, Rayyan was used to manage the screening workflow and enable blinded decisions by reviewers. The platform’s AI prediction tools were not used to determine study inclusion. Study selection was conducted manually by the reviewers according to the predefined eligibility criteria. Duplicate entries were removed and four members of the review team (OO, MA, DE, and EN) independently screened the titles and abstracts of the remaining entries to identify potentially relevant studies. Disagreements were resolved by the lead author (VOF). Subsequently, full-texts of the articles were screened for eligibility by four independent reviewers (OO, MA, DE, and EN). Disagreements within each pair of reviewers were resolved by the lead author (VOF). Eligible articles were included for extraction. The study selection process is shown in Fig. 1.

Fig. 1.

PRISMA Flowchart Diagram of the Study Selection Process. ^aA few studies reported outcomes in more than one publication

Data extraction

Once the final list of included studies was determined, four members of the review team (OO, MA, DE, and EN) began data extraction in Google Sheets. The following details were extracted from the included studies: Publication date, Study type, Geographic region, Setting (rural/urban), Top-line characteristics of the population (e.g. sex and population size), Intervention characteristics, Specific outcome(s) and Quality assessment. Where outcome data were incomplete or insufficiently reported, attempts were made to derive missing statistics from the information provided in the article (e.g., confidence intervals, p-values, sample sizes, or event counts). If key outcome data could not be obtained or reliably estimated, the study was retained for narrative synthesis but excluded from the relevant quantitative meta-analysis. Study quality assessment was conducted independently by four reviewers (OO, MA, DE, EN). Conflicts were resolved by discussion among team members or with the help of a third reviewer (VOF).

Data synthesis

The findings were summarized through quantitative and narrative syntheses. A narrative synthesis was conducted to report study themes, barriers, and facilitators associated with the interventions. We conducted a meta-analysis of the impact of short messaging services on family planning and modern contraceptive uptake practices. Outcomes were summarized using odds ratios, standardized mean difference (for knowledge outcomes), and 95% confidence intervals. Reported odds ratios were transformed to the natural logarithmic scale prior to pooling, and standard errors were calculated from reported confidence intervals where necessary. Pooled estimates were back-transformed for interpretation. Where a single study reported both one-way and two-way SMS intervention arms against a shared control group, comparisons were entered into separate subgroup analyses. Heterogeneity was measured using I² and Chi square tests. Subgroup and leave-one-out sensitivity analyses were conducted to evaluate source of heterogeneity. The operational definitions of these subgroups are provided in Table 1. Publication bias was assessed using the funnel plot and Begg’s test. All quantitative syntheses were conducted using the random-effects model in R version 4.4.3, due to anticipated clinical and methodological heterogeneity across studies.

Table 1.

Definitions of subgroup moderators used in the meta-analysis

Moderator	Category	Operational Definition
Region	East Africa	Studies conducted in countries classified within the East African subregion of Sub-Saharan Africa, as defined by the African Union [19].
	West Africa	Studies conducted in countries classified within the West African subregion of Sub-Saharan Africa, as defined by the African Union [19].
	Central Africa	Studies conducted in countries classified within the Central African subregion of Sub-Saharan Africa, as defined by the African Union [19].
	Southern Africa	Studies conducted in countries classified within the Southern African subregion of Sub-Saharan Africa, as defined by the African Union [19].
Intervention duration	Short term (≤ 3 months)	SMS interventions delivered for a total duration of three months or less.
	Medium term (3–6 months)	SMS interventions delivered for a duration between three to six months.
	Long term (> 6 months)	SMS interventions delivered for longer than six months.
Frequency of SMS	Weekly	Participants received SMS messages once per week.
	Sub-weekly	Participants received SMS messages more than once per week (e.g., daily or multiple times weekly).
Mode of SMS delivery	One-way	SMS messages were sent to participants without the option for participants to respond or interact with the system.
	Two-way	SMS interventions that allowed participants to respond, ask questions, or engage in interactive communication with the system or health provider.
Personalization	Generic	SMS messages that were standardized and not tailored to individual participant characteristics.
	Interactive/Personalized	SMS messages that were tailored to the participant (e.g. behavioral responses, individualized feedback, or adaptive messaging).
Content	Reminders	Messages that focused primarily on reminding participants to take or use modern contraceptives, attend appointments, or follow scheduled actions.
	Information	Messages that primarily delivered educational content about family planning or modern contraceptive use.
	Hybrid	SMS messages that combined both informational content and behavioral reminders.

Assessment of methodological quality

The authors assessed the methodological quality of the studies that were selected for retrieval according to procedures described by The Cochrane Collaboration’s tool for assessing risk of bias. We employed RoB2 for randomized controlled trials and the ROBINS-I tools for non-randomized trials of interventions [20]. We employed the Joanna Briggs Institute Critical Appraisal Checklist for qualitative studies. Conflicts in the risk of bias assessment were assessed by a third reviewer.

Assessment of certainty of evidence

We graded the overall certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework [21]. GRADE assessments were conducted by a single reviewer (VOF) and independently reviewed by two authors (MA and PG), for the modern contraceptive uptake and contraceptive knowledge outcomes. Evidence was evaluated across the domains of risk of bias, inconsistency, indirectness, imprecision, and publication bias. The certainty of evidence was categorized as high, moderate, low, or very low. Based on the assessment, a summary of findings table was generated.

Results

Study characteristics

From 258 identified records, we included 21 publications reporting 16 studies (multiple publications arose from some studies) in this review. The full PRISMA flow diagram for this study is provided in Fig. 1. Of the studies included in this review, there were 10 randomized controlled trials [8–13, 15, 22–25], 4 quasi-experimental studies [4, 14, 16, 26, 27] and 2 pilot studies [5, 28]. The studies were conducted in 7 countries, with 10 conducted in Kenya, and one each conducted in Ghana, Malawi, Mozambique, Nigeria, Tanzania, and Uganda. The total sample size was 16,849 participants. The study sample was 81.5% female. While most interventions targeted women of reproductive age, a few targeted adolescent girls and young persons [9, 13, 16, 27], pregnant women [11, 15, 22], and the general population [5, 10, 28]. One study each was directed at men [4], couples [26], and sex workers [24]. Personal phone ownership ranged from 66% [8] to 100% [14, 24]. The study characteristics are summarized in Table 2.

Table 2.

Study characteristics

First author	Year of Publication	Country	Study Design	Sample size (pre/control)	Sample size (post/intervention)	Age range (years)	Number of females (percentage)	Population
Leight et al. [8]	2022	Mozambique	Randomized controlled trial	1801	1822	18–45	3623 (100%)	Women of reproductive age
L’Engle et al. [5]	2013	Tanzania	Pilot study	2870	2870	≤ 19 – ≥40	553/995 (56%)	General population
Vahdat et al. [28]	2013	Kenya	Pilot study	4817	4817	≤ 19 – ≥40	650/1062 (61.2%)	General population
Rokicki et al. [9]	2017	Ghana	Randomized controlled trial	293	205; 258	10–19	756 (100%)	Adolescent girls
Johnson et al. [10]	2016	Kenya	Randomized controlled trial	1444	1419	≤ 19 – ≥40	-	General population
Laidlaw et al. [16, 27]	2018	Malawi	Quasi-experimental study	129	127a	15–25	128 (50%)	Young people
McConnell et al. [22]	2018	Kenya	Randomized Controlled Trial	122	225	18–40	347 (100%)	Pregnant women
Green et al. [12]	2018	Kenya	Randomized controlled trial	56	56	18–35	112 (100%)	Market women
Unger et al. [11]	2018	Kenya	Randomized encouragement Trial	100	100; 100	≥ 14	300(100%)	Pregnant women
Jones et al. [23]	2020	Kenya	Randomized Controlled Trial	377	120	N/A	511(100%)	Women
Ampt et al. [24]	2020	Kenya	Cluster Randomized Control Trial	401	385	16–34	786 (100%)	Sex workers
Matoke et al. [4]	2024	Kenya	Quasi Experimental Study	120	120	N/A	0 (0%)	Men
Sampson et al. [14]	2023	Nigeria	Quasi Experimental Study	105	103a	18–49	105 (100%)	Women of reproductive age living in internally-displaced persons’ camps
Kamulegeya et al. [7, 26]	2022	Uganda	Quasi experimental study	551	450a	18–55	101 (18.3%)	Men and their current active sexual partner
Harrington et al. [15]	2019	Kenya	Randomized Control Trial	130	130	19–28	260 (100%)	Pregnant women
Mwaisaka et al. [13, 25]	2021	Kenya	Randomized controlled trial	236	504	18–24	347 (46.9%)	Youths

^a Difference between pre- and post-intervention because of participant drop-off

Intervention Characteristics

Two-way messages were reported in six studies [5, 10, 14, 15, 26, 28], and one-way messages were reported in nine studies [4, 7, 8, 12, 13, 16, 22–24]. Two studies reported using both one-way and two-way SMS [9, 26]. Two studies reported including calls in the intervention [14, 26]. Most interventions utilized generic messaging [4, 7, 8, 12–14, 16, 22–24, 26], with a few utilizing interactive or personalized messages [5, 9–11, 15, 28]. Attrition was generally low, with only two studies recording above 30% attrition [8, 12]. The frequency of interventions ranged from on-demand [5, 10, 28], to once every few days [16, 23, 24, 26, 27], to once every week [8, 9, 11, 13, 15]. In Sampson et al.’s study [14], the SMS was sent biweekly. SMS content included clinic visit and contraceptive use reminders [8, 11, 12, 22], information on family planning and pregnancy prevention [4, 5, 7, 9–11, 13–16, 23, 24, 26, 28], and information on where to access family planning clinics [10]. The median intervention duration was six months (IQR: 2.5–9.5 months). The intervention characteristics are summarized in Table 3.

Table 3.

Intervention characteristics

First author	Year of Publication	Content of SMS	Frequency	Personalization	Intervention duration (months)	Duration of follow-up (months)	Directionality	Integrated services
Leight et al. [8]	2022	Reminders to visit a clinic for family planning	Weekly	Generic	1	1	One-Way	Clinic appointments
L’Engle et al. [5]	2013	Information on eight family planning methods.	On-demand	Interactive	10	10	Two-way	N/A
Vahdat et al. [28]	2013	Information on nine family planning methods	On-demand	Interactive	17	17	Two-way	N/A
Rokicki et al. [9]	2017	Pregnancy prevention, information on reproductive anatomy, pregnancy, STIs, contraception (male condoms, female condoms, birth control pills, emergency contraception)	Weekly	Both	3	15	Both	N/A
Johnson et al. [10]	2016	Benefits, disadvantages, and side effects of nine family planning methods; a searchable database of clinics that offer family planning counseling and services	On-demand	Interactive	9	9	Two-way	N/A
Laidlaw et al. [16, 27]	2018	Contraception and different contraception methods (male condoms, female condoms, pill, injections, implants, IUDa, SDMb, withdrawal, ECPc, female sterilization, vasectomy)	3 times a week	Generic	2	6	One - way	Counselling
McConnell et al. [22]	2018	Reminders	One-off	Generic	-	5 weeks	One - way	Vouchers
Green et al. [12]	2018	Reminders	On-demand	Generic	4	-	One-way	N/A
Unger et al. [11]	2018	Topics covered by the SMS included ANCd, pregnancy problems, family planning, newborn health, EBFe, infant vaccinations, and reminders for visits.	Weekly	Personalized	12 weeks postpartum	24-week postpartum	Both	N/A
Jones et al. [6]	2020	Birth spacing, modern methods of contraception, reminder that they can get pregnant again soon after birth before having periods	Every 3 days	Generic	1.5	-	One-way	Postpartum Checklist (PPC) messages and general postnatal care messages and reminders
Ampt et al. [24]	2020	Promotion of contraception, especially long-acting reversible contraception and the usage of dual method contraceptives, was the main focus of the WHISPER messaging content.	2–3 times weekly for 12 months	Generic	12	6th month, 12th month	One-way	None
Matoke et al. [4]	2024	Informative content	Once weekly	Generic	4	-	One-way	N/A
Sampson et al. [14]	2023	Factual information about family planning	biweekly	Generic	10	-	Two-way	Counselling, community awareness sessions, calls to male partners
Kamulegeya et al. [7, 26]	2022	Messages on modern contraception	2 messages weekly	Generic	6	1, 4, 6 months	Two-way	Phone call and SMS with health professionals, referrals and links to other health services
Harrington et al. [15]	2019	Automated message content centered around FPf (approximately two thirds of all messages), and included information about available methods and their effectiveness, postpartum pregnancy risk, contraceptive safety during lactation, anticipatory guidance about side effects, community misperceptions, and dual protection. The remaining third of messages were focused on general perinatal topics, such as healthy pregnancy and exclusive breastfeeding.	Weekly	Personalized	6	6	Two-Way	N/A
Mwaisaka et al. [13]	2021	SRHg information to dispel myths and misconceptions around contraception.	Weekly	Generic	7 weeks	7 weeks	One-way	N/A

^aIUD: Intrauterine contraceptive device

^bSDM: Standard Days Method

^cECP: Emergency Contraceptive Pill

^dANC: Antenatal care

^eEBF: Exclusive breastfeeding

^fFP: Family planning

^gSRH: Sexual and Reproductive Health

Contraceptive uptake

Data on improvements in modern contraceptive uptake was reported in ten studies [5, 8–11, 14, 15, 23, 24, 28]. The meta-analysis revealed a significant improvement in contraceptive/family planning utilization (OR: 1.41, 95% CI: 1.26–1.57; p = 0.000149). There was evidence of low heterogeneity in the pooled data (I² = 0.0%, Tau² = 0, p = 0.59), indicating consistent findings across studies and suggesting that the pooled effect estimate is robust. The effect of interventions on contraceptive uptake is shown in Fig. 2.

Fig. 2.

Forest plot of effect sizes for modern contraceptive uptake

Subgroup analysis

Subgroup analysis was conducted to stratify studies by region, intervention duration, frequency, mode of SMS delivery, personalization, and content. Based on region and SMS frequency, there was no statistically significant difference between subgroups. Interventions longer than 6 months (p < 0.0001), two-way messages (p = 0.0402), personalized messages (p = 0.0265), and hybrid content (p < 0.0001) were more effective at enhancing modern contraceptive and family planning uptake. The results of the subgroup analysis are shown in Table 4.

Table 4.

Subgroup analysis for moderators of effect size

Moderator	OR	95% CI	k	p-value
Region
East Africa	1.55	1.06–2.26	4	0.3448
West Africa	1.63	1.12–2.36	3
Southern Africa	1.39	1.21–1.59	1
Intervention duration
Short term (≤ 3 months)	1.37	1.22–1.55	5	< 0.0001*
Long term (> 6 months)	1.91	1.78–2.05	3
Frequency of SMS
Weekly	1.38	1.23–1.55	6	1.000
Sub-weekly	1.85	1.85–1.85	2
Mode
One-way	1.39	1.20–1.80	5	0.0402*
Two-way	1.76	1.13–2.74	3
Personalization
Generic	1.38	1.21–1.59	5	0.0265*
Interactive/Personalized	1.78	1.14–2.79	3
Content
Reminders	1.39	1.21–1.59	1	< 0.0001*
Information	1.37	1.11–1.69	5
Hybrid	1.93	1.64–2.28	2

Assessment of publication bias

We assessed publication bias using the funnel plot and Begg’s test. Begg’s rank correlation test of funnel plot asymmetry yielded a bias estimate of -2 0.00 with a p-value of 0.8046, indicating that there is no significant evidence of publication bias among the included studies. Figure 3 shows the funnel plot for assessing publication bias.

Fig. 3.

Funnel plot for assessment of publication bias

Sensitivity analysis

Leave-one-out sensitivity analysis showed stability of the odds ratio across all exclusions (range: 1.39–1.47), indicating that no study caused undue influence on the findings of the meta-analysis. Figure 4 shows the sensitivity analysis results of the studies.

Fig. 4.

Leave-one-out sensitivity analysis

Knowledge of family planning

A key theme explored was enhancements in knowledge and awareness of family planning as a result of SMS interventions, as reported in six studies [4, 7, 10, 14, 16, 24]. Multiple studies reported improvements in knowledge, although the extent varied between studies. Johnson et al. [10] and Ampt et al. [24] reported modest improvements in knowledge scores, while Laidlaw et al. [16] and Matoke et al. [4] reported significant improvements in knowledge scores. Atuhaire et al.’s study [7] qualitatively reported improvements in knowledge. Sampson et al.’s study [14] reported significant increases in awareness of family planning, with 101 participants becoming aware of family planning post-intervention as opposed to 56 at the beginning of the study. However, the positive study-level findings did not translate into a consistent pooled effect.

The meta-analysis proved inconclusive, showing no significant improvement in modern contraceptive knowledge (pooled SMD: 0.29, 95% CI: -0.12–0.69). There was evidence of significant heterogeneity (I² = 89.6%, Tau² = 0.12, p < 0.0001). Figure 5 shows the forest plot of SMS intervention effects on contraceptive knowledge. Qualitative findings were synthesized narratively to contextualize the quantitative results and were not included in the pooled effect estimates of the meta-analysis.

Fig. 5.

Forest plot of effect sizes for modern contraceptive knowledge

Couple communication and male partner involvement in family planning

Couple communication and involvement of male partners in family planning was also explored in some studies [4, 15, 26]. All studies reported improvements in couple communication and male partner involvement in family planning, citing that interventions helped male partners better understand their responsibility in family planning and contraceptive use. This is highlighted in the study by Matoke et al. [4] with an OR of 4.4306.

Barriers and facilitators

Barriers and facilitators to intervention success were explored in some studies. Challenges highlighted limited mobile phone access [15, 16], lack of male partner consent/participation [14, 15], fear of side effects [14], myths and sociocultural beliefs [14], lack of funds [14], and literacy barriers [15]. The study by Leight and colleagues [8] was conducted during the pandemic and cited the state of emergency during that period as a key barrier. Facilitators of intervention success included confidentiality [28], use of simple language [28], interactive messaging [15], and integration with post-partum care services [15].

Quality assessment

Study quality was assessed using the Cochrane Risk of Bias tool (RoB2) [29] for randomized controlled trials, the ROBINS-I tool [30] for non-randomized studies of interventions, and the JBI Critical Appraisal Checklist for Qualitative Studies for publications reporting qualitative studies [31]. From the assessment using RoB2, 7 of 11 studies had moderate to low risk of bias. For the non-randomized trials of interventions, only 2 studies had moderate risk of bias. From the assessments, only two studies included in the meta-analysis for the primary outcome were judged to have a moderate risk of bias; the rest were deemed to have a high risk of bias. These methodological limitations should be considered when interpreting the pooled effect estimates, as they may influence the reliability of the observed intervention effects. Because of the small number of studies with quantitative data, we did not exclude studies from the meta-analysis based on risk of bias scores.

The results of these assessments are presented in Figs. 6, 7, 8 and 9.

Fig. 6.

Traffic light plot of risk of bias for included RCTs

Fig. 7.

Summary light plot of risk of bias for included RCTs

Fig. 8.

Traffic light plot of risk of bias for included non-randomized trials

Fig. 9.

Summary plot of risk of bias for included non-randomized trials

Certainty of evidence

Using the GRADE framework, the certainty of evidence for the contraceptive uptake outcome was rated as low. Evidence was downgraded by two levels for risk of bias, primarily due to methodological limitations in several included studies, as most studies reporting this outcome had high risk of bias. No downgrades were applied for inconsistency, indirectness, imprecision, or publication bias. For the contraceptive knowledge outcome, the certainty of evidence for this outcome was also rated as low. Evidence was downgraded for inconsistency, reflecting heterogeneity in the reported effects across studies, and downgraded for imprecision, as the confidence interval crossed the line of no effect. The summary of findings is presented in Table 5.

Table 5.

Summary of findings of the GRADE assessment of certainty of evidence

Outcome	No. of Studies	Study Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Participants (n)	Effect Estimate (RR/OR/MD with 95% CI)	Certainty of Evidence (GRADE)
Contraceptive Uptake	10	Mixed (RCTs, QE)	-2a	0	0	0	0	15,472	1.41 (95% CI: 1.26–1.57)	⨁⨁◯◯ (Low)
Contraceptive Knowledge	6	Mixed (RCTs, QE)	0b	-1c	0	-1d	0	3135	0.29 (95% CI: -0.12–0.69)	⨁⨁◯◯ (Low)

^aMost of the included studies for this outcome had a high risk of bias

^bOnly two of the studies had a high risk of bias

^cThe heterogeneity (as measured by I²) was greater than 60%, hence the evidence was downgraded

^dThe evidence was downgraded as the 95% confidence interval included a null value

Discussion

SMS-based interventions constitute a scalable mobile health (mHealth) strategy to improve health outcomes through accessible and cost-effective communication. In this systematic review and meta-analysis, we address a critical gap by providing information that is integral to the future creation of interventions aimed at improving family planning and contraception in sub-Saharan Africa. Previous studies have explored the application of mHealth in the utilization of Sexual and Reproductive health services broadly [32] and the use of mHealth in improving modern contraceptive uptake in low- and middle-income countries [33]. Our study builds on these efforts by evaluating the effectiveness of Short Messaging Services (SMS)-based interventions in promoting modern contraceptive and family planning utilization in sub-Saharan Africa.

Our results show that SMS-based interventions are highly effective in improving the uptake of family planning and modern contraceptives. Moreover, it has highlighted a few components that may be integral to the successful optimization of these interventions. Parameters such as longer intervention duration (> 6 months), two-way messaging, and personalized messages were found to be more effective, underscoring the value of interactivity and user-centered design in SMS-based strategies. Although our study does not point out the exact reasons these parameters are more effective, it is plausible that these features enhance user engagement and foster emotional connection to the intervention. These “intimate” features may be critical factors in the effectiveness of SMS-based interventions. Further research should compare different SMS interventions based on these parameters to further test the validity of the aforementioned hypothesis. Additionally, while neither regional differences nor SMS frequency reached statistical significance, variations in Odds Ratio (East Africa: 1.41, West Africa:1.63) suggests that contextual factors such as sociocultural norms and differences in existing digital health infrastructure may influence outcomes.

Our results differ from findings from similar studies in high-income regions. For example, a systematic review by Zapata et al. [34], which included studies from the United States (U.S), New Zealand, Europe and Australia provided inconclusive evidence in the effectiveness of reminder systems in improving outcomes. An updated review by Zapata et al. [35] yielded similar findings. Cartwright et al. [36] also reported that mHealth interventions had limited effectiveness in improving contraceptive behaviors however maintains that they improve knowledge. The reasons for these geographic discrepancies remain unclear, however, it is noteworthy that several studies included in our review were assessed as having a moderate to low risk of bias. This is in contrast to Zapata et al. [34] and Zapata et al. [35] which may partially explain the discrepancy.

Beyond promoting behavioral change, SMS-based interventions have demonstrated value in enhancing family planning and contraceptive knowledge, fostering couple communication and facilitating male partner involvement in family planning [37]. Despite these successes, several barriers to the implementation of these interventions persist. Some, such as the requirement for male partner consents and the prevalence of myths and misconceptions are primarily sociocultural and necessitate targeted advocacy and community engagement with key stakeholders [37, 38]. Other challenges such as insufficient funding, illiteracy and states of emergency are more structural problems that may require broader health system interventions. Notable facilitators such as confidentiality, use of simple language, bidirectional communication and integration with postpartum care services were identified [39]. Unlike external barriers, these facilitators are modifiable components of the interventions and may serve as critical determinants of the intervention success. Exploring these elements may provide potential areas for future research.

Strengths and limitations

This study possesses several methodological and contextual strengths that enhance its credibility and relevance. First, it follows a systematic review and meta-analytic design, guided by the PRISMA framework, ensuring transparency and rigor in the study selection, data extraction, and synthesis processes. The inclusion of a wide range of study designs including randomized controlled trials, quasi-experimental studies, and qualitative research enables a comprehensive understanding of the impact of SMS-based interventions across diverse contexts in Sub-Saharan Africa. Moreover, the study integrates quantitative and qualitative data, allowing for both statistical generalizability and contextual interpretation of findings.

Subgroup analyses further strengthen the study by revealing intervention characteristics that are significantly associated with improved outcomes. These insights are particularly useful for designing future mHealth strategies. Additionally, the risk of publication bias was assessed and found to be low, and sensitivity analyses confirmed the robustness of the main findings, lending credibility to the results.

Despite these strengths, the study is not without limitations. One key limitation is the high heterogeneity observed in knowledge-related outcomes, which may stem from differences in intervention content, delivery frequency, and assessment tools used across studies. This limits the strength of inferences that can be drawn about the effect of SMS interventions on modern contraceptive knowledge. Secondly, most of the included studies focused on short- to medium-term outcomes, limiting our ability to assess the long-term sustainability of behavioral changes such as continued contraceptive use.

Another limitation of this review relates to the methodological quality of some included studies. A number of studies included in the meta-analysis were assessed as having a high overall risk of bias. These biases largely arose from confounding, selection of participants, and outcome measurement limitations. Furthermore, the certainty of evidence for the main outcomes was rated as low. As a result, the pooled estimates should be interpreted with caution, as the true effect of SMS interventions on family planning and modern contraceptive uptake may differ from the estimates reported in this review.

Additionally, the review involved studies from only three databases and included only studies published in English, which may have resulted in a selection bias.

Finally, the influence of sociocultural and contextual variability such as differing levels of digital literacy, gender norms, and mobile access across regions was not uniformly accounted for in the primary studies, posing a challenge to cross-contextual interpretation. These limitations highlight the need for future research that employs standardized metrics, explores long-term outcomes, and prioritizes equity in intervention design and population reach.

Conclusion

In conclusion, SMS-based interventions show promise in improving modern contraceptive use and family planning uptake in sub-Saharan Africa particularly when they are personalized, interactive, and embedded within broader reproductive health strategies. Phone and SMS services were largely accessible, suggesting the feasibility of large-scale and potentially regional implementation. Moreover, policies should be developed to support the sustainability of these interventions either directly or by enabling the aforementioned facilitators. Future research should evaluate the long-term behavioural outcomes beyond uptake and explore strategies for tailoring interventions to reach vulnerable subgroups including adolescents and low-literacy populations. SMS-based interventions hold significant potential to mitigate the challenges associated with contraceptive use and family planning and should be utilized in our region’s pursuit of improving family planning and contraception.

Abbreviations

SDGs

Sustainable Development Goals

SMS

Short messaging service

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-analyses

PROSPERO

International Prospective Register for Systematic Reviews

MeSH

Medical Subject Headings

RoB2

Revised Cochrane Risk of Bias Tool for Randomized Trials

ROBINS-I

Risk of Bias in Non-randomized Studies – of Interventions

SMD

Standardized Mean Difference

Authors’ contributions

VOF: Conceptualization, Project Supervision, Investigation, Data Acquisition, Writing – Original Draft, Writing – Review & Editing. OO: Data Extraction & Cleaning, Writing – Original Draft, Writing – Review & Editing. MA: Data Extraction & Cleaning, Writing – Original Draft, Writing – Review & Editing. PG: Investigation, Writing – Original Draft, Writing – Review & Editing. DE: Data Extraction & Cleaning, Writing – Original Draft, Writing – Review & Editing. EN: Data Extraction & Cleaning, Writing – Original Draft, Writing – Review & Editing. OVA: Investigation, Writing – Original Draft, Writing – Review & Editing. All authors read and approved the final manuscript.

Funding

No funding was received for this study.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.